October 2008—At Bangkok's Ramathibodi Hospital, a TREAT Asia site since 2003, the benefits of expanded access to antiretroviral therapy (ART) are evident—more patients are surviving and follow-up rates are high. But physicians there are also confronting the new realities of the epidemic, including a shortage of doctors to treat increasingly long-lived HIV patients and the threat of resistance to common first-line anti-HIV medications.

According to Dr. Somnuek Sungkanuparph, an attending physician in Ramathibodi Hospital's division of infectious diseases and the principal investigator for TREAT Asia research projects at the hospital, his country's successful expansion of access to treatment has given his patients the opportunity to live longer and better lives. However, the reality of extended lives means that treatment needs to be extended, too, which requires more staff at major hospital centers like Ramathibodi Hospital. Like other large teaching hospitals inThailand, Ramathibodi Hospital attracts patients from around the country seeking treatment from its HIV specialists; indeed, the hospital's HIV/AIDS caseload currently numbers more than 2,000 people.

"We have to see them all," said Dr. Somnuek, explaining that some patients choose to travel to Bangkok and pay for treatment there rather than use their local hospitals.

In addition to ART, Ramathibodi Hospital provides prophylaxis and treatment for opportunistic infections, HIV testing and counseling, HIV education for patients and healthcare providers, and advanced laboratory testing. Despite the demands of managing a large caseload, Dr. Somnuek noted that the hospital is able to treat so many people successfully because of the increased availability of generic ART.

"Seven or eight years ago, we had almost all the medicine that was available in the U.S., but 90 percent of our patients could not pay for it," he said. "We had about 10 or 20 patients each day who were hospitalized with HIV and opportunistic infections." Now, he explained, 90-95 percent of his patients who need ART can receive treatment with generic drugs, which are largely subsidized by the national AIDS program. "Our patients can go back to work and be with their families; they can get a job and can function in society," he continued. "I think that's a really big change here in Bangkok and in Thailand, and it's also something that inspires doctors, nurses, and other medical personnel to help us, because they can see how much they can change the patients' quality of life."

One complication doctors in Thailand and around the world are encountering is resistance to first-line ART regimens—a factor that is threatening the long-term success of treatment scale-up efforts. To address this issue, Ramathibodi Hospital participates in numerous research studies, including the TREAT Asia Studies to Evaluate Resistance (TASER). This research project was established to create a system for monitoring the emergence and spread of drug resistance throughout Asia, which is crucial to identifying effective secondline treatments.

Ramathibodi Hospital, which has been participating in TASER since 2006, has enrolled more than 120 patients in the study so far and plans to enroll up to 200, approximately 10 percent of its patients. By studying this sample, doctors are gaining insight into how many patients are resistant. "We've never seen that picture before," said Dr. Somnuek. In addition, participation in TASER means that the hospital's lab is now part of the TREAT Asia Quality Assurance Scheme, which is helping to standardize the performance of labs across the region.

About five percent of the clinic's patients show signs of drug resistance 24 months after the initiation of treatment, according to Dr. Somnuek. Most treatment failure, he said, results from imperfect adherence to the most commonly used ART in Thailand—an NNRTI-based regimen—which is inexpensive, easy to take, and causes few adverse effects but must be taken correctly at least 95 percent of the time in order to work effectively. Other patients who have been referred to Ramathibodi Hospital experience treatment failure after taking a suboptimal first-line regimen prescribed by physicians who lack experience and knowledge of ART.

In addition to contributing data to TASER, Ramathibodi Hospital is part of the TREAT Asia HIV Observational Database (TAHOD), and has contributed data to TAHOD's published research. The hospital's participation in the database not only helps TREAT Asia develop a more accurate picture of epidemic trends in the region, but also allows doctors to share experiences with other TREAT Asia sites. Learning from other physicians in the region, said Dr. Somnuek, "inspires us to do better and to develop goals that we may be able to achieve in the future."